National health mission

National health mission

1. NATIONAL HEALTH MISSION : NRHM

2. National Health Mission (NHM) encompassing two Sub-Missions National Rural Health Mission (NRHM) National Urban Health Mission (NUHM).

3. OBJECTIVES • Describe in detail about the National Rural Health Mission • Discuss the core strategies and implementation of National Urban Health Mission • Explain in detail on the national health mission

4. HEALTH SCENARIO • Multiple burden of disease –communicable, noncommunicable and unattended morbidities • High child and maternal deaths • 50% under nourished and anemic women and children – very little improvement • Water and sanitation challenges remain • Food security • Malaria, dengue, chikunguniya on the rise • Public health regulation – very weak • High TFR in UP, Bihar, MP, Rajasthan, Jharkhand

5. National Rural Health Mission The National Rural Health Mission was launched since April 2005 throughout the country for providing better rural health services. National rural health mission has special focus on following 18 states: • Empowered action group (EAG) states: Bihar, Jharkhand, MP, Chattisgarh , Up, Uttaranchal, Odisha and Rajasthan. • North east states: Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura. • Other states: Himachal Pradesh, Jammu and Kashmir

6. National Rural Health Mission (NRHM) was launched at the National Level in April 2005 for a period of seven years ( 2005-2012)extended up to year 2017.

7. VISION • The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure.

8. MISSION • The Mission is an articulation of the commitment of the Government to raise public spending on Health from 0.9% of GDP to 2-3% of GDP . • The mission will be the instrument to integrate multiple vertical programmes along with their funds at the district level

9. AIMS • The main aim of NRHM is to provide accessible,affordable , accountable, effective and reliable primary health care and bridging the gap in ruralhealth care through the creation of a cadre of Accredited Social Health Activist. • provision of a female health activist in each village • Health & Sanitation Committee of the Panchayat • Indian Public Health Standards (IPHS) • Integration of vertical Health & Family Welfare Programmes

10. – Mainstream AYUSH into the public health system. – Effective integration of health concerns with determinants of health like sanitation & hygiene, nutrition , and safe drinking water through a District Plan for Health. – It shall define time-bound goals and report publicly on their progress. • It seeks to improve access of rural people,especially poor women and children, to equitable , affordable, accountable and effectiveprimary healthcare

11. GOALS • Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR ) • Universal access to public health services such as Women’s health , child health, water, sanitation & hygiene,immunization , and Nutrition. • Prevention and control of communicable and noncommunicable diseases , including locally endemic diseases • Access to integrated comprehensive primary healthcare • Population stabilization, gender and demographic balance. • Revitalize local health traditions and mainstream AYUSH • Promotion of healthy life styles

12. OBJECTIVES OF NATIONAL RURAL HEALTH MISSION • To reduce Maternal Mortality Rate (MMR) • To reduce Infant Mortality Rate (IMR) • To reduce Total Fertility Rate (TFR

13. To provide accessible, affordable, accountable,effective and reliable primary health care, especially to poor and vulnerable sections of the population • To provide the overarching umbrella to the existing programmes of health and family welfare including malaria, blindness, iodine deficiency, filarial, kala-azar, tuberculosis control and RCH II • maximum coordination can be achieved among the related social sector, department of AYUSH, women and child development, elementary education,panchayati raj and rural development.

14. APPROACHES • Increasing participation and ownership by the community • Improved management capacity • Flexible financing • Innovations in human resources development for the health sector • Setting of standards and norms with monitoring

15. Expected outcomes of NRHM • IMR reduced to 30/1000 live births by 2012 • Maternal mortality reduced to 100/100000 live births by 2012 • TFR reduced to 2.1 by 2012 • Malaria mortality reduction rate – 50% up to 2010 , additional 10% by 2012. • Kala Azar mortality reduction rate -100% by 2010 and sustaining elimination until 2012 • Filarial/ microfilaria reduction rate – 70% by 2010 , 80% by 2012 and elimination by 2015

16. • Dengue mortality reduction rate – 50% by 2010 and sustaining at that level until 2012 • Cataract operations – increasing to 46 lakhs until 2012 • Leprosy prevalence rate – reduce from 1.8 per 10000 in 2005 to less than 1 per 10000 thereafter • Tuberculosis DOTS series – maintain 85% cure rate through entire mission period and also sustain planned case detection rate • Upgrading all community health centres to Indian public health standards • Increase utilization of first referral units from bed occupancy by referred cases of less than 20% to over 75 % • Engaging 400000 female accredited social health activists (ASHAs)

17. Community level targets • Availability of trained community level worker at village level,with drug kit for generic ailments. • Health day at Anganwadi level on a fixed day/ month for provision of immunization, antenatal / postnatal check-ups and services related to mother and child health care,including nutrition • Availability of generic drugs for common ailments at sub centre and hospital level. • Access to good hospital care through assured availability of doctors , drugs and quality services at PHC/CHC level and assured referral transport communications systems to reach these facilities in time . • Improved access to universal immunization through induction of Auto disposable syringes, alternate vaccine delivery and improved mobilization services under the programme

18. • Janani Surakshya Yojana (YSY) for the below poverty line families • Availability of assured health care at reduced financial risk through pilots of community health insurance under the mission • Availability of safe drinking water • Provision of household toilets • Improved outreach services to medically underserved remote areas through mobile medical units • Increase awareness about preventive health including nutrition

19. STRATEGIES • Strengthening of the health institutions providing Primary Health Care (CHCs, PHCs and Sub Centres) so as to provide all the basic and emergency obstetric care • Strengthening of the routine immunization for the vaccine preventable diseases. • Improving the health services and the services determining the health of the society viz sanitation and potable drinking water. • Decentralizing the health planning and management of the health institutions by way of Constitution of District Health Missions and District Health Societies • Formation of Rogi Kalyan Samitis (RKS) and Village Health Sanitation and Nutrition Committees (VHSNC). • Bringing all the centrally sponsored Health schemes under the umbrella of NRHM.

20. PLAN OF ACTION FOR STRENGHENING THE INFRASTRUCTURE AND MANPOWER • Creation of ASHA (accredited social health activist ): every village will have female accredited social health activist • Strengthening sub-centres – United fund of Rs. 10000 per annum – Supply of drugs both allopathic and AYUSH – Additional ANMs / Multipurpose worker (male) – Upgrading existing sub centres – Sanction of new sub centres

21. • Strengthening primary health centres – Adequate and regular supply of essential quality drugs and equipments including auto disabled syringes for immunization – Provision of 24 x 7 service in at least 50% PHCs – Mainstreaming of AYUSH man power – Following standard guidelines and standing protocols – Provision of a second doctor at PHC level (one male and one female ) – Up gradation of 100% PHCs for 24 hours referral service

22. • Strengthening community health centres for first referral services – Operationalizing the existing CHCs (30 to 50 beds) as 24 hour FRUs including posting of anaesthetists – New Indian public health standards (IPHS) for CHCs – Promotion of Rogi kalian Samiti (RKS) for hospital management – Developing standards of services and costs in health care – Display of citizens charter at PHC/CHC level .

23. The schedule of implementation of major components of NRHM is as follows : Merger of multiple societies and constitution of district/ state mission : June 2005 Provision of additional generic drugs at SC/PHC/CHC level : December 2005 Operational programme management units : 2005-06 Preparation of village health plans : 2006 ASHA at village level (with drug kit) : 2005-08 Upgrading of rural hospitals : 2005-07 Operationalizing district planning : 2005-07 Mobile medical unit at district level : 2005 -08

24. GOALS TO BE ACHIEVED BY NRHM NATIONAL LEVEL • Infant mortality rate reduced to 30/1000live births • Maternal mortality ratio reduced to 100/100000 • Total fertility rate reduced to 2.1 • Malaria mortality rate reduction -50% by 2010,additional 10% by 2012 • Kala-azar mortality rate reduction – 100% by 2010 and sustaining elimination until 2012 • Filaria / microfilaria rate reduction – 70% by 2010, 80% by 2012 and elimination by 2015

25. • Dengue mortality rate reduction – 50% by 2010 and sustaining at that level until 2012 • Japanese encephalitis mortality rate reduction – 50% by 2010 and sustaining at that level until 2012 • Cataract operation : increasing to 46 lakhs per year by 2012 • Leprosy prevalence rate : reduce from 1.8/10000 in 2005 to less than 1/10000 thereafter • Tuberculosis DOTS services : maintain 85% cure rate through entire mission period • Upgrading community health centres to Indian Public Health Standards • Increase utilization of first referral units from less than 20% to 75% • Engaging 250000 female Accredited Social Health Activist (ASHAs) in 10 states.

26. COMMUNITY LEVEL • Availability of trained community level worker at village level, with a drug kit for general ailments • Health day at anganwadi level on a fixed day/ month for provision of immunization, ante/postnatal checkups and services related to mother and child health care including nutrition . • Availability of generic drugs for common ailments at sub centre and hospital level. • Good hospital care through assured availability of doctors , drugs and quality services at PHC/CHC level

27. • Improved access to universal immunization through induction to auto disabled syringes, alternate vaccine delivery and improved mobilization services under the programme . • Improved facilities for institutional delivery through provision of referral, transport, escort and improved hospital care subsidized under the Janani Suraksha Yojana for the below poverty line families • Availability of assured health care at reduced financial risk through pilots of community health insurance under the mission . • Provision of household toilets • Improved outreach services through mobile medical unit at district level.

28. MAINSTREAMING AYUSH • The Mission seeks to revitalize local health traditions and mainstream AYUSH infrastructure, including manpower, and drugs, to strengthen the public health system at all levels. • AYUSH medications shall be included in the Drug Kit provided at Village levels to ASHA. • The additional supply of generic drugs for common ailments at Sub Centre/PHC/CHC levels under the Mission shall also include AYUSH formulations . • At the CHC level, two rooms shall be provided for AYUSH practitioner and pharmacist under the Indian Public Health System (IPHS) model. • Single doctor PHCs shall be upgraded to two doctor PHCs by mainstreaming AYUSH practitioner at that level.

29. ASHA – Accredited Social HealthActivist • ASHA must be primarily a woman resident of the village ‘Married/ Widow/ Divorced” and preferably in the age group of 25 to 45 yrs. • ASHA should have effective communication skills,leadership qualities and be able to reach out to the community. • She should be a woman with formal education up to Eighth Class. • Adequate representation from disadvantaged population groups should be ensured to serve such groups better.

30. Compensation to ASHA • ASHA is a honorary volunteer and would not receive any salary or honorarium. • she could be compensated for her time in the form of TA and DA. • She can also be given awards, non- monetary incentives etc. Drug kit is given free.

31. MONITORING AND EVALUATION Process indicators : (a) Numbers of ASHA seleted by due process (b) Number of ASHA trained (c) % of ASHA attending review meeting after one year . Outcome indicators : (a) % of newborn who were weighed and families counselled (b) % of children with diarrhoea who received ORS (c) % of institutional deliveries

32. (d) % of JSY claims made to ASHA (e) % completely immunized in 12-23 months age group (f) % of unmet need for spacing contraception among BPL (g) % of fever cases who received chloroquine within first week in an malaria endemic area; Impact indicators : (a) IMR (b) child malnutrition (c) number of case of TB/ leprosy cases detected as compared to previous year.

33. ROLE AND RESPONSIBILITY OF ASHA • ASHA will be the health activist in the community who will create awareness on health • She will take steps to create awareness and provide information to the community • She will counsel women on birth preparedness,importance of safe delivery, breast feeding and complementary feeding, immunization,contraception and prevention of common infections including reproductive tract infection /sexually transmitted infection and care of the young child.

34. She will mobilize the community and facilitate them in accessing health and health related services available at the anganwadi / sub centre / primary health centres • She will work with the village health and sanitation committee of the gram Panchayat to develop a comprehensive village health plan • She will arrange escort/ accompany pregnant women and children requiring treatment/ admission to the nearest pre-identified health facility i.e., primary health centre / community health centre/ first referral unit.

35. • She will provide primary medical care for minor ailments such as diarrhoea, fevers, and first aid for minor injuries. • She will be a provider of directly observed treatment short – course (DOTS) under revised national tuberculosis control programme. • She will also act as a depot holder for essential provisions being made available to every habitation . • A drug kit will be provided to each ASHA.

36. • Her role as a provider can be enhanced subsequently . • She will inform about the births and deaths in her village and any unusual health problems/disease outbreaks in the community to the Sub-centres/ Primary Health Centre. • She will promote construction of household toilets under Total Sanitation Campaign .

37. Role and integration with anganwadi • Organizing Health Day once/twice a month. • On health day, the women, adolescent girls and children from the village will be mobilized for orientation on health related issues • AWW to participate and guide organizing the Health Days at Anganwadi Centre (AWC). • AWW and ANMs will act as resource persons for the training of ASHA.

38. • IEC activity through display of posters, folk dances etc. • Anganwadi worker will be depot holder for drug kits and will be issuing it to ASHA. • AWW will update the list of eligible couples and also the children less than one year of age in the village with the help of ASHA. • ASHA will support the AWW in mobilizing pregnant and lactating women and infants for nutrition supplement.

39. Role and integration with ANM • She will hold weekly / fortnightly meeting with ASHA and discuss the activities undertaken during the week/ fortnight . • She will guide her in case ASHA had encountered any problem during the performance of her activity. • AWWs and ANMs will act as resource persons for the training of ASHA • ANMs will inform ASHA regarding date and time of the outreach session and will also guide her for bringing the beneficiary to the outreach session. • ANM will participate and guide in organizing the health days at anganwadi centres • She will take help of ASHA in updating eligible couple register of the village concerned.

40. • She will utilize ASHA in motivating the pregnant women for coming to sub centre for initial check-ups . • She will also help ANMs in bringing married couples to sub centres for adopting family planning. • ANM will guide ASHA in motivating pregnant women for taking full course of Iron and folic acid tablets and tetanus toxoid injections etc. • ANMs will orient ASHA on the dose schedule and side effects of oral pills • ANMs will educate ASHA on danger signs of pregnancy and labour so that she can timely identify and help beneficiary in getting further treatment. • ANMs will inform ASHA on date, time and place for initial and periodic training schedule. • She will also ensure that during the training ASHA gets the compensation for performance and also TA/DA for attending the training

41. SPECIAL INITIATIVES • GERIATRIC CARE PROJECT • COMMUNITY BASED MENTAL HEALTH PROJECT • POLY CLINIC SERVICES • RADIO HEALTH • TELE MEDICINE • MOBILE DISPENSARY • PALLIATIVE CARE PROJECT • MCTS